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Pelee Island as a System

To start with, I want to arrange the key actors in this scenario using the hierarchical model (Figure 3.1). Starting with the environment, the most obvious representation of Level 5 in this accident is a climate that resulted in Lake Ontario freezing in winter and, thus, requiring alternative provisions for travel. The local weather at the time is also an environmental factor. It directly impacted activity at Level 1 through its effects on aircraft operations and the pilot’s subsequent need to respond appropriately. It also triggered behaviour at Level 2 through the need to undertake de-icing, a process often requiring outside support. Weather has an effect at Level 3 because of the increased probability of rescheduling flights in adverse weather with subsequent knock-on effects for rostering, crew duty times, aircraft positioning, etc. The distribution of the population can be considered an environmental factor in that it created a demand for year-round communication links for isolated communities. It was this policy that resulted in the need to substitute an air link in winter when ice prevented ferry sailings.

Transport Canada represents Level 4 in the systems model. Transport Canada has a responsibility to ensure the safe and efficient conduct of aviation within its jurisdiction. To achieve this it has processes in place to ensure that air routes are viable and that air carriers’ work within the rules. The primary vehicle for exercising control is the Canadian Aviation Regulations. This framework of rules, guidelines and

A hierarchical model of aviation

FIGURE 3.1 A hierarchical model of aviation.

standards represents the constraints that must be met in order to hold an approval to operate. The regulations are amplified through the air operator’s certificate (AOC) manual that specifies the steps needed to acquire and maintain an AOC. One requirement of an AOC holder is to develop a set of manuals containing information for crews on the operation of aircraft and the conduct of flight. These manuals are open to inspection by the regulator.

Oversight of air operators is conducted through a network of operations inspectors and the work of the inspectors is described in the operations inspector manual. Inspectors conduct scheduled and no-notice checks and audits and have the power to demand changes to company processes. Transport Canada has the authority to impose various forms of punishment on offenders ranging from fines to the cancellation of an AOC, thereby causing an air operator to cease functioning. This body of rules and regulations represents a historical trace of the decision-making process at the level of the regulator in relation to risk management.

The division of responsibilities within Transport Canada that resulted in a significant change to an AOC not being communicated to the Georgian Express Principal Operations Inspector (POI) flowed from a decision about how to organise resources within Transport Canada and the subsequent allocation of responsibilities. The ambiguous nature of the Pelee Island route - a subsidised charter on behalf of the Government of Ontario being operated in the guise of a scheduled service - further clouded the question of responsibility for oversight. These confusions resulted in a breakdown in control.

The Government of Ontario, Georgian Express and the Cessna Aircraft Corporation represent Level 3 in my framework. The regional government allocates resources in relation to policies associated with supporting communication between remote communities. The role of the company is to organise and provision, to initiate, sustain, modify and to terminate production activity as required. This is the domain of management decision-making. It put in place a process for documenting flights using load sheets and passenger manifests. It made available equipment for de-icing the aircraft at remote locations. The company exercised control over line operations through procedures. Cessna builds aircraft, which are tools of production. The aircraft, itself, represents the output from a set of decisions taken in relation to meeting a demand for a particular class of aircraft suited to a specific set of conditions. Control is exercised through operating procedures and performance limitations. The township of Pelee operates the airport and also represents a Level 3 actor. Because of its proximity to the USA it is considered a port of entry into Canada and has immigration facilities but being a small regional airport, the size of aircraft it can handle is limited and it has no air traffic control tower. The range of traffic management services it offers is limited. The sophistication of services offered by the airport, then, reflects decisions made about the need and available finance. The airport staff had no control over events that day but the configuration of the asset - the airport - shaped the pilot’s options in dealing with the aircraft’s performance issues.

Level 2 in my system model captures collaboration. In a formal sense, although the Cessna was operated by a single crew member, the pilot interacted with the company dispatchers and also with air traffic control en route to Pelee Island. We can also see elements of informal collaboration. Observers on the ground commented on the presence of ice to the pilot. From the accident report, there is little evidence to illustrate control being exercised at this level other than this interaction between the pilot and the person on the ground. It is conjecture but, for the purposes of this discussion, this event represents communication across a notional interface in relation to an operational issue. The presence of ice was significant enough to trigger the comment. It is possible that the differing status of the two actors - pilot v non-pilot - captures the power dynamic and, thus, who exercised control.

Level 1 has, historically, been the main focus of accident investigation. It was here that the pilot applied his skills of operating the Cessna Caravan within the procedural context of flight management. He made decisions about loading the aircraft, preparing it for flight and manipulating the device to get airborne. Control was exercised through inputs to the aircraft. Feedback was available through the performance of the aircraft.

Systems are configured with sufficient controls in place to afford predictability. Feedback loops generate signals that confirm that the system is behaving the way stakeholders expect. However, operations on a daily basis are subject to perturbations and deviations and actual performance can often be at variance with what was anticipated. Systems can accommodate departures from intended action to the extent that the operation has sufficient buffering capacity. Accidents and incidents occur when activities exceed the bounds of control.

 
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